How the QSI Informs the Support Plan Ron DeSantis Governor Barbara Palmer APD Director Good morning, thank you for joining us today. Before we begin, I would like to remind everyone that this training is an hour long and is worth 1.5 CEUs. At the end of the training, there will be an assessment auto-generated and sent to your email. Please complete the assessment before 5 pm today. A score of 4 or higher will be a passing score and you will earn 1.5 CEUs. The Test Results page is your certificate. Please save this page for your records. We will be monitoring the chat box throughout the training. This training will have interactive moments, so please utilize the chat box to send your answers. As always, we will address your questions at the end of the call, so please hold your questions until then. Again, thanks for joining and let’s begin! 1
Topics covered in this module include: - Defining significant risks and needs - Identifying strategies to meet assessed needs - Developing the “Other Services Needed for Health and Safety” section of the Support Plan Today, we will cover the following topics related to the support planning process: Defining significant risks and needs How to identify strategies How to develop Other Services Needed for Health and Safety Please note that the information in this training is meant to provide a framework for understanding how to fill out the person-centered support plan related to needs and risks. This training is not meant to be the only source of understanding regarding how to address specific needs and significant risks. For further information, resources will be provided at the end of the training. Throughout this training, we will refer to the Person-Centered Support Plan. 2
Defining an Effective Support Plan Meaning Agreement Motivation To start off, let’s briefly review the three aspects of an effective support plan. As you have been using the new Person-Centered Support Plan, you may have asked yourself, “What makes a good support plan good?” or, “What is the difference between a support plan that is just words and a support plan that actually leads to a better quality of life?” All support plans should look different, since every person’s life and needs are unique. However, all good support plans will be developed based on three main ingredients: meaning, motivation, and agreement. Meaning A meaningful support plan is one that captures what the individual desires. It is their vision for their life that drives the process of achieving goals and making the support plan effective. Without meaning, it will not matter what is recorded in the support plan; no one will desire to follow through to make it happen. Motivation Closely related to meaning is motivation. A good support plan will motivate all members to get on board with the vision and stay committed to seeing it through. Agreement The last ingredient in a effective support plan is agreement. In fact, there is no plan if the members of the support team are not in agreement of the various elements of the plan and how to carry it out. A vital role as a WSC is to make sure that ALL members of the circle of supports are clear about the information recorded in the support plan, what it means for them, and that they agree to work together to assist the person to make the plan a reality. 3
Assessed Needs and Risks Needs Risks Consequences Role of WSC Choice Health and Safety An important element of a support plan is that it clearly identifies needs and any significant risks present in their life. While it is important to support the individual to pursue their dreams and goals, you could ask: What would happen if you only planned for what the person expressed as a want or desire? What if I ignored their obvious needs and potential risks in their life? As with anyone, when health and safety needs are not addressed, serious consequences to the individual or others can occur. Person-centered planning puts the individual at the center of their life choices, which means that there will always be a certain amount of risk related to these choices. Support coordination cannot eliminate risks completely, but it is the role of the WSC to ensure that the person’s health and safety are maintained to the fullest extent possible. With that, it is equally important that the person has a choice regarding how their health and safety will be maintained. It is important to remember that an individual must have sufficient information to understand the choices available, including pros, cons, and the impact of their choice. It is the WSC’s responsibility to provide the information and discuss all options with the individual so that the realities, consequences, and risks are presented and understood. 4
What is a Significant Risk? Significant risks are needs that, if not addressed, could result in institutionalization, medical attention, legal action, or place the individual or others in danger. So, what is a significant risk? Significant risks are needs that, if not addressed, could result in institutionalization, medical attention, legal action, or place the individual or others in danger. The foundation for person-centered planning is the principle of self-determination, which states that the individual has the right to control and direct their life. It’s important that both the individual and their circle of supports understand the role that risk plays when the individual is making their own life choices. The WSC has the important responsibility of ensuring that the consumer is provided with opportunities to experience real choice without endangerment. With that, the WSC also has the responsibility to make sure that the individual and his or her supports understand the potential risks and what strategies are available to minimize them. 5
Assessing Needs and Risks Who to Talk to: What to Review: • Family • QSI • Day Program • Medical Reports • Residential Staff • Provider Reports • Job Coach • Legal Documents • People Important to the Customer What other information do you use when assessing needs and risks? Reviewing documentation (such as the QSI) is important in identifying risks. However, it is not the only avenue that a WSC must explore. During the development of the support plan, other supports should also be consulted, such as day program, residential staff, supported living coach, or family. Having conversations with supports is necessary to clarify information you read in documents like the QSI, medical reports, or other provider progress notes. Sometimes, what is read in one document may not be reflected in another, or there may be conflicting information. Since the WSC is the facilitator of all information gathering and assessing, it is imperative that you have as many conversations and read as much documentation as necessary to get a clear picture of the individual’s needs. If information within the person’s QSI is found to be either inaccurate or misleading, contact your local APD office so an up-to-date QSI can be done. What other information do you use when assessing needs and risks? Please use the chat box to send in your examples. 6
•Identify needs •Provide information The Role of for funding the QSI •Social integration •Detect possible risk Federal rules require that the support plan “reflect clinical and support needs as identified through an assessment of functional need.” The plan must “reflect risk factors and measures in place to minimize them, including individualized back-up plan and strategies when needed.” The QSI is the agency’s assessment tool used to identify needs and potential health or safety risks and is part of a full needs assessment process. For the purposes of this training, we will not go into detail on the content and process of conducting the QSI, but we can summarize the purpose of the QSI in providing important support plan information. The assessment is designed to facilitate an interview process that will: a) identify a person’s needs for supports and services, b) provide relevant information for use of a resource allocation algorithm to assign a funding range for each person receiving services, c) estimate a person’s degree of social integration into the community and stimulate efforts to improve social integration, and, lastly, d) detect possible risks or threats and alert the individual’s supports so that undue hardship, illness, or harm is avoided. 7
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